Anterior sacral meningocele in pregnancy

Anterior sacral meningocele is a rare condition characterized by the herniation of meningeal membranes and cerebrospinal fluid through a defect in the anterior aspect of the sacrum. We present the case of a 26-year-old patient with an anterior sacral meningocele which had been discovered during gynaecologic surgery because of a cystic pelvic mass. Subsequently, the patient underwent two pregnancies. The management of a pregnancy complicated by a coexisting anterior sacral meningocele presents a challenging problem for the obstetrician. Because of the high maternal mortality due to rupture of the meningocele under labor, primary cesarean delivery is indicated as soon as fetal lung maturity is established and was performed in our patient in both pregnancies in the 35 week, without complications for mother and children.     

Sonography in the diagnosis and management of anterior sacral meningocele

Four cases of anterior sacral meningocele (ASM) are described, with comparisons between radiological and sonographic findings. On plain films, 2 cases showed the classic scimitar sign, and 1 case showed a defect in the anterior sacrum. The other lesion appeared radiologically to be a purely intrasacral meningocele. Myelography outlined part of the ASM in two cases. Sonography demonstrated the anterior sacral cysts in all cases. Sonography is a noninvasive method of monitoring progress or contraction of a lesion, and it can be used to demonstrate any associated pathology. The combination of plain-film appearances and sonographic findings should be sufficient for diagnostic purposes. If an operative procedure is contemplated, then myelography may be performed in an attempt to outline the stalk.     

Anterior sacral meningocele: management in gynecological practice.

We describe the case of a young woman with anterior sacral meningocele (ASM), initially identified during a routine ultrasound examination and subsequently diagnosed using magnetic resonance imaging (MRI). ASM is a rare disorder characterized by uni- or multilocular extensions of the meninges from the sacral spinal canal to the retroperitoneal presacral space. Common symptoms include lower back and pelvic pain, constipation, difficulties in defecation, dysmenorrhea and dyspareunia, and urinary incontinence, retention or urgency. Perineal and lower-extremity paresthesias may present when nerve roots are affected. Despite its more posterior location, ASM can mimic an ovarian cyst or other adnexal cystic mass, and in the obstetric patient can present a mechanical obstacle to delivery with a risk of rupture and infection during labor and delivery. Although it is a rare condition, we feel that awareness of the etiology, presentation and imaging characteristics of ASM is of importance and have therefore carried out a review of the literature, taking into account case findings and the obstetric and gynecological management of this disorder.     

Pressure changes under the ischial tuberosities of seated individuals during sacral nerve root stimulation

Neuromuscular stimulation via the sacral nerve roots is proposed for prevention of ischial pressure ulcers following a spinal cord injury (SCI). Acute effects of sacral functional magnetic stimulation (FMS) on seat interface pressure changes were investigated in five nondisabled volunteers. Similar effects were demonstrated with functional electrical stimulation in people with SCI who used a sacral anterior root stimulator implant. The results indicated that sacral nerve root stimulation, either by FMS or implanted electrical stimulation, induced gluteus maximus contraction and mild pelvic tilt sufficient for clinically significant reductions in ischial pressures during sitting.     

Three‐dimensional power Doppler sonography in the diagnosis of a cystic sacrococcygeal teratoma mimicking a meningomyelocele: A case report

Sacrococcygeal teratomas have been diagnosed prenatally on sonograms as masses of cystic, solid, or mixed echogenicity from the sacral area and protruding through the perineum or buttocks. However, a cystic sacrococcygeal teratoma may be misdiagnosed as an anterior sacral meningomyelocele, especially when presenting as a posterior cystic mass. We report a case in which three‐dimensional power Doppler imaging was helpful for making a correct prenatal diagnosis of a type 1 cystic sacrococcygeal teratoma, which mimicked a meningomyelocele. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound, 2009     

骶正中动、静脉解剖变异对脊柱腰骶椎前路手术的临床意义

目的对骶正中动静脉的位置分布及变异进行解剖观察及实际测量其与周围重要结构的位置关系,为临床医师提高腰骶椎前路手术安全性提供必要的参考信息。方法收集2008年5月-2011年1月期间l因疾病及意外死亡者新鲜人体尸体标本30例,对其进行解剖学研究,观察并测量骶正中动、静脉的发出点与走行,骶正中动、静脉的数量与缺失情况,以及骶正中动、静脉间的相互走行关系。结果①骶正中动脉在主动脉发出以及走行的位置相对固定,无明显多支与缺失情况;骶正中动脉均为腹主动脉根部背侧发出,未见发出点位于左右髂总动脉。发出后行于左侧髂总静脉后方,跨过腰5／骶1椎间盘下行。骶正中静脉与骶正中动脉伴行的情况占总数的60．0％;②骶正中静脉多支常见,没有发现有骶正中静脉的缺失。1支的占总标本数的66．7％,2支的占30．O％,3支的占3．3％。结论当选择分叉下入路,应该特别注意骶正中动静脉的解剖位置。动脉的变异相对较小,而静脉的变异程度非常大,发出点变异,多支的情况多见,这些原因都造成了静脉容易损伤的原因,在手术中应该特别注意。     

Interface pressure and cutaneous hemoglobin and oxygenation changes under ischial tuberosities during sacral nerve root stimulation in spinal cord injury

Noninvasive functional magnetic stimulation (FMS) of the sacral nerve roots can activate gluteal muscles. We propose the use of sacral anterior root stimulator (SARS) implants to prevent ischial pressure ulcers in the spinal cord injury (SCI) population. In this study, we (1) investigated the acute effects of sacral FMS on ischial pressure, skin blood content, and oxygenation changes in people with SCI and demonstrated the utility of FMS as an assessment tool, and (2) showed that similar effects are possible with electrical stimulation via a SARS implant. Results indicated that sacral nerve root stimulation, either by FMS or implanted electrical stimulation, induced sufficient gluteus maximus contraction to significantly change subjects' ischial pressures and cutaneous hemoglobin and oxygenation during sitting. In addition to these beneficial acute effects, chronic stimulation via a SARS implant may build gluteal muscle bulk and prevent or reduce pressure ulcers in the SCI population.     

Approach in anterio with posterior to curettage and local puring chemotherapy with radiotherapy to treatment elevation sacral tumors

Objective To observe the results of treatment the high level sacral tumors by the surgical technique of approach in anterior with posterior to curettage and local pouring chemotherapy with radiotherapy and to discuss the feasibility of this surgical technique.Methods 24 cases,includde the oncology results,the funmctions of the sacral nerves and the complications were analyzed.Results Average follow-up 56 months,3 malignant cases were died of the tumor metastasis,4 recurrent cases were recurred after treatment between 13 and 32 months.4 cases were found sinuses in the drainage-tube.This surgical technique was not significant influence on the functions of the sacral nerves.Conclusions This method is safe and effeciveness in treatment of elevation sacral tumors.     

影像学诊断Currarino综合征

目的 探讨Currarino综合征的影像表现及不同影像学检查方法对各种伴发畸形的诊断价值。方法 回顾性分析经手术证实的9例Currarino综合征患儿的临床及影像学资料。9例患儿均行腹部平片及消化道造影（或瘘管造影）,8例行MSCT扫描,5例行骶尾部MR扫描。结果 9例患儿中6例为肛门闭锁,其中4例伴直肠会阴瘘,3例为肛门直肠狭窄。骶尾骨畸形：6例患儿为一侧骶骨缺如,表现为“弯刀征”,2例表现为椎体融合,1例表现为骶尾骨短小,发育不良。骶前包块：5例为畸胎瘤,4例为骶前脊髓脊膜膨出伴脊髓栓系。结论 Currarino综合征临床少见,但具有特征性影像表现。影像检查能对其明确诊断。对Currarino综合征患儿进行影像学检查时应注意骶尾骨发育情况及有无骶前包块。     

前后联合入路局部刮除置管灌注化疗及放疗术治疗高位骶骨肿瘤

Fortheelevationsacraltumorstoobtainthesurgicalsafemarginbyresectionisverydifficult.Thereportsaboutthecasesofsacrec-tomypointedoutthecomplications,includingcomplexsurgery,tremendoustraumaandsacralnervalfunctionalbereavement,wereserious犤1-3犦.Weusedthealternativesurgicalprocedurewhichwasapproachinanteriorwithposteriortocurettageandlocalpouringchemotherapywithradiotherapytotreat24casesofthehighlevelsacraltumorsandtheresultsofclinicaluseaboutthissurgicaltechniquewasfine.1Materialsandmethods1.1Gen…     

The sacral hiatus approach for drainage of anterior lumbo-sacral epidural abscesses. A case report and technical note

Lumbosacral epidural abscesses are managed either conservatively with IV antibiotics or with open surgery, particularly in the presence of acute neurological symptoms. Their location makes it difficult for image-guided interventional approaches either for biopsy or evacuation. We report the sacral hiatus and canal as a corridor for image-guided minimally invasive abscess of lumbosacral epidural abscess for aspiration. A 56-year-old man presented to the emergency department complaining of six weeks of worsening low back pain. MRI of the patient's lumbosacral spine showed osteomyelitis involving his L5, S1 vertebrae, L5-S1 discitis, as well as an anterior epidural abscess extending from L4-5 disc space to the S2 vertebral level. Blood cultures grew out gram-positive cocci. For drainage, a 5-French micropuncture kit was utilized to access the hiatus. Under fluoroscopic guidance a microwire was then advanced along the sacral canal. An 18-gauge needle curved to approximate the contours of the sacral canal was then advanced over the guidewire. Once anatomic access was established 2 ml of thick purulent material was aspirated. The patient tolerated the procedure well, and no focal nerve root symptoms were noted following the procedure. Image-guided aspiration of lumbosacral epidural abscesses can thus be carried out in a safe and effective manner using a sacral hiatus approach.     

Needle electrode insertion into tibialis posterior. A new approach

The tibialis posterior can be a valuable muscle in the electrodiagnostic evaluation of the sacral plexus, lumbosacral roots, lower extremity neuropathies and tibial nerve lesions. It may be under utilized, however, because it is generally considered to be inaccessible to needle examination. The purpose of this study was to compare the widely recommended posterior approach to this muscle to an anterior approach that we define. In six cadaver legs, the safe access to this muscle via the anterior approach was 16.8 +/- 5 mm by contrast to 9.5 +/- 2 mm by the posterior approach. We conclude that the anterior approach to needle electromyography of the tibialis posterior muscle is easier, safer and deserves more widespread practice.     

Laparoscopic sacral colpopexy: a proposed technique

This case report describes a laparoscopic sacral colpopexy using Mersilene mesh in a patient with complete vaginal vault prolapse. Mersilene mesh was placed as a hammock between the vaginal apex and the anterior surface of the sacrum, using intracorporeal needles and an extracorporeal knot tying technique. Minor modifications are made from the traditional abdominal approach, because the patient had previously undergone a pelvic lymphadenectomy and vaginal cuff radiation for a stage IB grade 1 adenocarcinoma of the endometrium.     

Comparison of direct bladder and sacral nerve stimulation in spinal cats.

Neuroprosthetic techniques have been used to facilitate voiding via electrical stimulation for bladder management following spinal cord injury (SCI), but high urethral resistance has been a problem. This problem was investigated here in the chronic, spinal, male cat (C6-T1) using direct bladder and sacral nerve stimulation. Direct bladder stimulation was only conducted during terminal procedures with an open abdomen and with four hook electrodes inserted into the bladder wall. Sacral stimulation was conducted daily during the 10 weeks post-SCI and during terminal procedures. Stimulation was conducted with both implanted epidural electrode and surface electrodes over the sacral bone. Both of these sacral methods stimulated anterior and posterior roots. However, these sacral methods were generally ineffective for inducing voiding during the study. In three of the five animals investigated, stimulation did not empty the bladder. In the remaining two animals, the bladder was emptied with sacral stimulation, but only after return of bladder reflex activity, 2 to 4 weeks post-injury. When poor voiding occurred in spite of high bladder pressures, it indicates high urethral resistance. This was confirmed using video cystourethrography where the membranous urethra was observed to remain closed following stimulation. Direct bladder stimulation was then compared to sacral nerve stimulation during terminal procedures. Direct bladder stimulation induced voiding at a high rate both during and after stimulation, whereas sacral nerve stimulation with implanted electrodes induced voiding at a lower rate and only after stimulation. A simple urethral resistance measure, the ratio of bladder pressure to voiding rate, was lower with direct bladder stimulation than sacral nerve stimulation. Stimulation-facilitated voiding has also been associated with the development of bladder wall hypertrophy. This problem was investigated by evaluating bladder wall thickness postmortem in three groups of animals: the first group was the spinal-stimulated animals detailed above; the additional two groups were a spinal-nonstimulated but instrumented group maintained for 10 weeks following injury, and an intact group of animals. The stimulated spinal cats tended to have the thickest bladder wall followed by the nonstimulated spinal cats. The wall thickness of intact animals served as a control.     

Ultrasound as a Screening Tool for Proceeding With Caudal Epidural Injections

Chen CP, Wong AM, Hsu C-C, Tsai W-C, Chang C-N, Lin S-C, Huang Y-C, Chang C-H, Tang SF. Ultrasound as a screening tool for proceeding with caudal epidural injections.

Objective

To study the anatomical structure of the sacral hiatus using ultrasound. Based on the sonographic images of the sacral hiatus, the feasibility of caudal epidural injection can then be assessed.

Design

Case-controlled study.

Setting

Rehabilitation outpatient clinic in a tertiary medical center.

Participants

Patients (N=47; 20 women, 27 men) with low back pain and sciatica who were to receive caudal epidural injection treatments were recruited into this study.

Interventions

Sonographic images of the sacral hiatus were obtained from all the patients. An ultrasound machine capable of examining musculoskeletal tissues with real-time linear-array ultrasound transducer was used to measure the distance between the anterior wall and posterior wall of the sacral hiatus (diameter of the sacral hiatus) and the distance between bilateral cornua.

Main Outcome Measures

Diameter of the sacral canal and distance between bilateral cornua measured in millimeters.

Results

The mean diameter of the sacral canal was measured to be 5.3±2.0mm in our recruited patients. The mean distance between bilateral cornua was measured to be 9.7±1.9mm. Caudal epidural injections failed in 7 patients. In these 7 patients, 4 had very small diameter of the sacral canal (1.6, 1.2, 1.4, and 1.5mm). In 1 man, sonographic images revealed a closed sacral hiatus (no sacral canal diameter can be measured). Two patients revealed flow of fresh blood into the syringe while checking for the escape of cerebrospinal fluid after the needles were inserted into the sacral canal. For safety reasons, steroid injections were not performed in these 2 patients.

Conclusions

Ultrasound may be used as an effective screening tool for caudal epidural injections. Anatomic variations of the sacral hiatus can be clearly observed using ultrasound. Sonographic images indicating a closed sacral canal and sacral diameters ranging from 1.2 to 1.6mm may suggest a higher failure rate in caudal epidural injection.     

Placental ultrasonography

Ultrasonography is the preferred technique for placental localization. It permits a comparatively precise estimate of the separation of the lower placental margin and internal cervical os. Six false positive diagnoses of placenta previa occurred in a series of 244 patients. There were no false negative diagnoses. The diagnosis of placenta previa was confirmed as correct in ten patients. Determination of the location of the lower margin of a posterior placenta obscured by the overlying fetus may be assisted by measurement of the separation of the anterior sacral margin and the fetal head when the latter is dipping into the pelvis. A separation of greater than 15 millimeters usually indicates extension of the lower placental margin over the sacral promontory and onto the lower uterine segment.     

Combined laparoscopic and perineal approach for the management of recurrent tailgut cyst

Tailgut cyst is an uncommon developmental anomaly arising from the embryonic hindgut in the retrorectal space. The patient frequently is asymptomatic or has vague perineal complaints that pose a diagnostic dilemma. Moreover, the patient is often misdiagnosed and therefore mismanaged. MRI is the investigation of choice for diagnosis. After the diagnosis is established, complete surgical excision is required to alleviate patient discomfort and to prevent complications such as infection, malignant transformation, and recurrence. Proper clinical examination and imaging not only establish the accurate diagnosis but also help in determining the best surgical approach for the patient (anterior abdominal, posterior sacral perineal, or combined approach). We hereby report a case of recurrent tailgut cyst managed with a combined anterior laparoscopic and perineal approach.     

Blood perfusion changes during sacral nerve root stimulation versus surface gluteus electrical stimulation on in seated spinal cord injury

The objective of this article is to examine dynamic changes of ischial blood perfusion during sacral nerve root stimulation against surface functional electrical stimulation (FES). Fourteen adults with suprasacral spinal cord injury (SCI) were recruited. The gluteal maximus was activated by surface FES or stimulating sacral nerve roots by functional magnetic stimulation (FMS) or a sacral anterior root stimulator implant (SARS). Ischial skin index of hemoglobin (IHB) and oxygenation (IOX) was measured.Skin blood perfusion was significantly higher during FMS than the baseline (IHB 1.05 ± 0.21 before vs.1.08 ± 0.02 during stimulation, p = 0.03; IOX 0.18 ± 0.21 before vs. 0.46 ± 0.30, p = 0.01 during stimulation). Similarly, when using the SARS implant, we also observed blood perfusion significantly increased (IHB 1.01 ± 0.02 before vs.1.07 ± 0.02 during stimulation, p = 0.003; IOX 0.79 ± 0.81 before vs. 2.2 ± 1.21 during stimulation, p = 0.036). Among four participants who completed both the FMS and FES studies, the magnitude of increase in both parameters was significantly higher during FMS. This study demonstrates sacral nerve root stimulation confer better benefit on blood perfusion than applying traditional FES in SCI population.     

Electromyographic activity of back musculature during Williams' flexion exercises

The purpose of this investigation was to determine the pattern and magnitude of electromyographic activity recorded from paraspinal musculature at four different vertebral levels while subjects performed six Williams' flexion exercises with anterior and posterior pelvic tilt. Bipolar surface electrodes were placed on the right sides, at C5, T6, L3, and S1, of eight men and eight women. Integrated electromyographic activity was analyzed at the end of range of each exercise. A significant (P less than .05) interaction effect was found between exercises and types of tilt at each vertebral level. The difference in electromyographic activity between the two pelvic positions was most evident in the lumbar and sacral areas, where electromyographic activity recorded for anterior tilt was greater than for posterior tilt. The results support the following conclusions: 1) pelvic tilt, curl up, knees to chest, and hamstring stretch performed with posterior tilt minimize the electromyographic activity in the lumbar and sacral regions that occurs in conjunction with lengthening of these muscles during posterior pelvic tilt, 2) use of the standing exercises and anterior tilt positions should be avoided if minimizing electromyographic activity in the lumbar and sacral regions is desired, and 3) the electromyographic activity of each of the four different vertebral levels responded independently of every other level during performance of Williams' flexion exercises.     

Neuro-urology--development of a new focus in rehabilitation of the spinal cord injured patient]

While preservation of renal function continues to be the primary objective in the urological care of spinal cord injured patients, new treatment principles have resulted in increased attention being given also to restoration of lost urinary continence, a goal shared by the patient as well. The fact that intermittent catheterization has stood the test also for the long-term management of micturition, as well as the development of effective medication for hyperreflective detrusor relaxation have resulted in a treatment concept that enables 70 percent of those treated to achieve dry intervals between catheterizations. Effective electromiction is today enabled by the sacral anterior root stimulator (Brindley), with continence ensured by sacral deafferentation performed at the same time; both measures have proved successful at medium term. Bladder augmentation is another operative measure for controlling detrusor hyperreflexia. Neurogenic urinary stress incontinence can be tackled successfully by implanting an hydraulic sphincter system (Scott). Both the advantages and the possible disadvantages or risks of these new management concepts are set out, dealing also with their indications. Successful treatment of erectile dysfunction is possible today, and inseminable sperma can be obtained in some 40 to 50 percent of the spinal cord injured patients.